ORIGINAL RESEARCH Endodontic Therapy Differential diagnosis and clinical management of periapical radiopaque/hyperdense jaw lesions Brunno Santos Freitas SILVA(a) Abstract: Great attention has been given to the study of radiolucent Mike Reis BUENO(b) Fernanda P. YAMAMOTO-SILVA(c) periapical lesions to avert possible misdiagnosis of apical periodontitis Ricardo Santiago GOMEZ(d) associated with certain radiolucent non-endodontic lesions. However, Ove Andreas PETERS(e) there are a significant number of radiopaque lesions found in the Carlos ESTRELA(c) periapical region, which could be equally relevant to endodontic practice. The diagnosis and management of these radiopaque/hyperdense (a) Universidade de Anápolis, School of Dentistry, Department of Oral Diagnosis, lesions could be challenging to the endodontist. These bone alterations Anápolis, GO, Brazil. could be neoplastic, dysplastic or of metabolic origin. In the context (b) Universidade de Cuiabá – UNIC, School of the more widespread use of cone-beam CT, a detailed review of of Dentistry, Department of Stomatology, radiopaque inflammatory and non-inflammatory lesions is timely and University of Cuiabá, Cuibá, MT, Brazil may aid clinicians perform a differential diagnosis of these lesions. (c) Universidade Federal de Goiás – UFG, Distinguishing between inflammatory and non-inflammatory lesions School of Dentistry, Department of simplifies diagnosis and consequently aids in choosing the correct Stomatologic Sciences, Goiânia, GO, Brazil. therapeutic regimen. This review discusses the literature regarding (d) Universidade Federal de Minas Gerias – the clinical, radiographic, histological and management aspects UFMG, School of Dentistry, Department of Oral Surgery and Pathology, Belo Horizonte, of radiopaque/hyperdense lesions, and illustrates the differential MG, Brazil. diagnoses of these lesions. (e) University of the Pacific, Arthur A. Dugoni School of Dentistry, Department of Keywords: Periapical Peridodontitis; Diagnosis, Differential. Endodontics, San Francisco, CA, United States of America. Introduction Declaration of Interest: The authors certify that they have no commercial or The decision-making process for a therapeutic protocol in root canal associative interest that represents a conflict infection must be based on an efficient diagnosis.1 Dental granuloma, of interest in connection with the manuscript. radicular cyst and periapical abscess represent periapical changes of frequent occurrence.2 The progressive stages of inflammation and periapical bone structure resulting in resorption are identified as Corresponding Author: exhibiting radiolucency on radiographic exams.3 However, radiopaque Carlos Estrela lesions are also identified near the apex of the teeth and should receive E-mail: [email protected] attention, because they may be of endodontic or non-endodontic origin.4 Osteoblastic and osteoclastic activity has been associated with low-grade chronic periapical inflammation.5 https://doi.org/10.1590/1807-3107BOR-2017.vol31.0052 Imaging exams could produce essential information about margination, the relationship between the lesion and adjacent teeth, and the internal content of the lesion, especially in cases containing calcified deposits.6.Great Submitted: Mar 03,2017 attention has been given to the study of radiolucent periapical lesions Accepted for publication: Apr 27, 2017 Last revision: May 21, 2017 to avert possible misdiagnosis of apical periodontitis (AP) associated with certain radiolucent non-endodontic lesions.4,7 However, there are Braz. Oral Res. 2017;31:e52 1 Differential diagnosis and clinical management of periapical radiopaque/hyperdense jaw lesions a significant number of radiopaque lesions that are the Oral and Maxillofacial Pathology textbook published found in the periapical region, which could be equally by Neville et al.2 were included in this study due to their relevant to endodontic practice.8,9,10,11 relevance in the area of oral pathology, and served as a Endodontic diagnosis is dependent on clinical and parameter in cases of any divergence in the information radiographic examinations. Periapical radiographs collected in the selected articles or lack of pertinent and cone beam computed tomography (CBCT) images information on certain diseases in the literature. A total represent important exams in the detection and diagnosis of 22 entities were described in the pertinent literature of inflammatory, dysplastic and neoplastic periapical (Table). Broadly, disease entities may be inflammatory, diseases.12,13,14 For many clinicians, the diagnosis and non-inflammatory, neoplastic and metabolic in nature. management of radiopaque/hyperdense lesions could The following review details clinical and radiographic be extremely challenging. In 1985, Bender and Mori features of specific diseases in the four groups. discussed the diagnostic considerations of certain periapical and periodontal radiopacities of endodontic Results and periodontal origin.15 A detailed review of radiopaque inflammatory and non-inflammatory lesions could be Inflammatory lesions opportune and aid the endodontist and clinician in carrying out a differential diagnosis of these lesions. Reactional osteogenesis This study reviewed the literature regarding the Reactional osteogenesis (RO) has been recently clinical, radiographic, histological and management described as an asymptomatic, localized radiopaque aspects of radiopaque/hyperdense lesions, and lesion occurring in the maxillary sinus and associated discusses the differential diagnoses of these lesions. to a molar apex compromised by secondary root canal infection. It is believed that RO is a response of the sinus Methodology mucosa to low-intensity and prolonged inflammatory aggression from an infected root canal, which results In the present study, a search was performed in the in the production of new bone on the superficial PubMed online database to identify the available studies, cortical of the maxillary sinus.12 RO is considered reviews and case reports on radiopaque/hyperdense an incidental radiographic finding characterized as inflammatory and non-inflammatory lesions of an ill-defined, dome-shaped, radiopaque thickening the jaws, particularly those that could occur in the that resembles a retention pseudocyst in conventional periapical region. The search included only articles radiographs. In CBCT images, this condition presents as in the following areas, published in English and a hyperdense, well-defined lesion, with a shape varying in indexed dental or medical journals, addressing from irregular to round to ovoid (Figure 1, A–C). information concerning radiopaque lesions: etiology; Except for the four cases described by Estrela et al.,12 clinical aspects; radiographic characteristics; histological there are no other reports or epidemiological studies characteristics; and management. An additional hand about this entity. In the study mentioned, all four cases search was performed in the following journals: Journal were detected in female patients between the fifth of Endodontics; Oral Surgery, Oral Medicine, Oral and seventh decades of life. Histologically, reactional Pathology, Oral Radiology; Oral Oncology; International osteogenesis presents bone tissue with distinct stages of Endodontic Journal; and Head and Neck Pathology. maturation, concentric layers of lamellae and organized The selected articles were included only when judged haversian systems, and may also show mature tissue, to contain relevant and pertinent information by the marrow and inflammatory cell infiltrate. From a authors of this study, representing different areas of therapeutic point of view, the treatment should focus dentistry (endodontics – CE and OAP; oral pathology on eradicating the root canal infection responsible for – BSFS and RSG; oral radiology – MRB and FPYS; and the maxillary sinus inflammation, and on eliminating oral medicine – FPYS). The World Health Organization the bone reaction; however, if this does not resolve the (WHO) Classification of Head and Neck Tumours16 and apical infection, surgical treatment is recommended. 2 Braz. Oral Res. 2017;31:e52 Silva BSF, Bueno MR, Yamamoto-Silva FP. Gomez RS, Peters AO, Estrela C. Table. Clinical, radiographic and epidemiological features of radiopaque/hyperdense lesions. Decadess of Gender/ Clinical/Radiographic Pulp Lesion Etiology Anatomical site Histopathological characteristics Management life/Age Race characteristics vitality Asymptomatic/ Diffuse Associated with the apex of Dense layers of compact bone Condensing Root canal I 3rd–7th NP radiopaque /Ill-defined an infected tooth/Alveolar – replacing fibrofatty bone marrow N osteitis therapy nonexpansile sclerotic image premolar or molar region and cancellous bone Asymptomatic/Ill-defined, dome- Bone tissue, concentric layers Root canal shaped, radiopaque/Thickening/ Reactional Maxillary sinus associated with the and haversian systems. Mature therapy/ I 5th–7th F Hyperdense, well-defined lesion N osteogenesis apex of an infected molar fibrofatty tissue, marrow and Surgical with irregular to round to ovoid inflammatory cell infiltrate treatment shape Varies from an isolated disease to a broader lesion comprising the entire hemi-mandible/ Variable symptomatic intensity, mandibular enlargement, lasting The same from a few days to several weeks, Primary chronic Necrotic bone tissue with treatment I Adolescence NP and sometimes accompanied by Mandible>maxilla UC osteomyelitis presence of bacterial colonies used for acute